“non-commercial” tb tests brief overview from msf perspective
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“Non-commercial” TB tests Brief overview from MSF perspective. Francis Varaine, MSF Retooling Task Force Geneva, 15-16/01/08. Content. Microscopy Bleach concentration Auramine staining FDA staining 2 slides Positivity threshold Culture and DST MODS Thin-layer agar Nitrate reductase - PowerPoint PPT PresentationTRANSCRIPT
“Non-commercial” TB tests Brief overview from MSF perspective
Francis Varaine, MSFRetooling Task Force
Geneva, 15-16/01/08
Content
Microscopy• Bleach concentration• Auramine staining• FDA staining• 2 slides• Positivity threshold
Culture and DST• MODS• Thin-layer agar• Nitrate reductase• Redox indicators• Kudoh method• Slide culture• …..
Microscopy
Bleach concentration method
• Centrifugation or sedimentation increases the sensitivity of the sputum smear microscopy.
• Angeby et al., IJTLD 2004 (literature review)– Recommend the evaluation and introduction of the bleach method in
most settings where mycobacterial culture is not performed routinely.
• Steingart et al., Lancet Infect Dis. 2006 (a systematic review)– Centrifugation with any of several chemical methods (including bleach)
is more sensitive, that overnight sedimentation preceded
– There were insufficient data to determine the value of sputum processing methods in patients with HIV infection.
• Bonnet et al (MSF), CID 2008. – Bleach sedimentation: An opportunity to optimize tuberculosis smear
microscopy in high HIV prevalence settings.
Adopted, introduced and implemented
Auramine staining
• Steingart et al., Lancet Infect Dis. 2006 : Fluorescence versus conventional sputum smear microscopy for tuberculosis: a systematic review. – Fluorescence microscopy is more sensitive than conventional microscopy,
and has similar specificity. – There is sufficient evidence to determine the value of fluorescence
microscopy in HIV-infected individuals
• LED • Study in Kenya : bleach + auramine
Adopted, introduced and implemented
FDA staining
• FDA (fluorescein) staining can be distinguish between live and dead AFB
• For diagnosis of true treatment failure.
• A. Hamid Salim, et al., Int J Tuber Lung Dis 2006. Early and rapid microcopy-based diagnosis of true treatment failure and MDR-TB.
• In Bangladesh:
Compared FDA staining and culture on smear positive sputum.
-Sensitivity 99%
-Specificity 82%
-Accuracy 93%
Operational research
New definitions
• 2 slides
• Positivity threshold : – 1 positive / 2 slides– 1 AFB / 100 fields
Bonnet, et al : Reducing the number of sputum samples examined
and thresholds for positivity: an opportunity to optimise smear
microscopy. IJTLD (2007)
Adopted, introduced and implemented
Rapid culture and DST
• Microcolonies
• Colorimetric methods
MODS Microscopic observation drug susceptibility
Based on characteristic cord formation in early liquid cultures
• Caviedes et al. JCM 2000; Moore et al. JCM 2004, NEJM 2006
• MTB detection rapid (median 7 days, 13 days BACTEC, 26 days LJ)
• Sensitive (98% vs 84%)
• RIF: sensitivity 100%; specificity 100%
• INH: sensitivity 84,6%; specificity 99.6%
Caviedes et al. J. Clin Microbiol 2000
Not adopted
TLA Thin Layer Agar
Based on detection of microcolonies on 7H10 agar
Characteristic “cording”
• Robledo et al., IJTLD 2006 (multicenter study)• Da Silva et. al., Braz. J. of Microbiology 2007
• Direct method for smear positive and negative specimens
• Median time to detection 10 days, for RIF and INH resistance
• Good sensitivity and specificity for direct DST (Robledo et al., submitted)
Picture: J. Robledo
Adopted for field testing
TLA multicentric study
Evaluation of a rapid culture method for tuberculosis diagnosis: a Latin American multi-center study.J. A. Robledo,G. I. Mejía, N. Morcillo,L. Chacón M. Camacho,J. Luna, J. Zurita, A. Bodon, M. Velasco, J. C. Palomino, A. Martin, F. Portaels. Int. J. Tuberc. Lung. Dis.10(6):613–619, 2006
Total of 1118 specimens studied in six sites
TLA for diagnosis
7H11 7H11 + PNB
Identification M. tuberculosis
Decontamination sputum sample NALC/NaOH
Reading with standard microscope
7H11 agar growth control
7H11 agar +PNB 500
7H11 agar + INH 0.2
7H11 agar + RIF 1
Decontamination sputum sample
Identification M. tuberculosis
Detection resistance INH Detection resistance RIF
Direct DST TLA INH/RIF
Reading with standard microscope
37°C 5%C02
+ ofloxacine under validation
Implementation of TLA in Homa Bay, Kenya (MSF)
TB culture lab.
Reading under normal microscope (objective 10x), twice a week
TLA procedure manual
http://www.itg.be
Rapid culture and DST
• Microcolonies
• Colorimetric methods
NRA (indirect)• Ängeby et al., JCM 2002, • Martin et al., JMM 2005 (multicentric study first-line drugs), • Martin et al., JCM, 2005 (ofloxacin)• INH, RIF, EMB, SM, OFLO• High accuracy (95-100%) for INH, RIF and OFLO• Median TAT: 10 days
NRA (direct) on sputum smear + samples• Musa et al. J Clin Microbiol 2005• Solis et al. Int J Tuberc Lung Dis 2005• Affolabi et al. J Clin Microbiol 2007• Median TAT: 14-28 days
Nitrate Reductase Assay (Griess method)
Considered for field testing
Study No. samples
Reference standard
INH Se/Spe
RIF Se/Spe
TAT (days)
Musa et al. 121 Direct PM 93/100 100/100 14 Solís et al. 192 Indirect PM 99/100 93/100 28*
Affolabi et al. 177 Indirect PM - 87.5/100 18
Nitrate Reductase Assay (Griess method)
Nitrate Nitrite
• Affolabi et al, JCM 2007• Performed on solid media• Rapid method for DST• Easy to implement in resource-limited countries• No need for training if implemented in lab where DST is already
performed on LJ.• No need of special equipment• Sensitivity 88%, specificity 100% • TAT: 18 days (direct)
Implementation of the NRA direct in Cotonou
Picture: Dr Affolabi, Benin
Colorimetric redox indicators
• Based on reduction of indicators by mycobacterial metabolism– Alamar Blue (Yaiko et. al JCM 1995)
– Resazurin (Palomino, AAC 2002)
• Martin et al. 2007 meta-analysis– 18 studies for RIF– 16 studies for INH
• Evidence of high sensitivity and specificity
• Other studies: EMB, SM, KAN, ETH, CAP, OFLO
Picture: A. Martin
MIC
Implementation of the resazurin in CotonouAffolabi et al., 2007 (submitted)
• Studied 151 strains of TB• Performed REMA and compared results with the gold standard PM on LJ for
RIF and INH• TAT REMA : 3 weeks + 8 days• Conventional method : 3 weeks + 4-6 weeks.
• Results – for RIF: 94% sensitivity and 100% specificity– for INH: 100 % sensitivity and 100% specificity
NRA procedure manual
http://www.itg.be
Colorimetric assay procedure manual
http://www.itg.be
Simplified culture
4% NaOH
Kudoh culture – Swab method
• Kudoh and Kudoh. Bull. World Health Org. 1974;51:71-82 : a simplified swab method for culturing mycobacteria that takes only 3-4 minutes per sample, and needs neither technical skill, centrifugation, nor a biosafety cabinet.
• Sputum is smeared onto a swab stick that is immersed into a test tube with sterile 4% sodium hydroxide.
• Very simple method to culture Mycobacteria in rural areas
• In 2006: evaluation of this method in Venezuela (Jacobus DeWaard, unpublish data)
• Kudoh swab method is as sensitive as the Petroff decontamination procedure in the diagnosis of pulmonary TB.
.
Medium Ogawa pH 6,4
• Evaluation of the Kudoh method in two hospital laboratories in Caracas, Venezuela and in the Warao Amerindian population (Orinoco River delta).
• All samples were processed for acid-fast staining and cultured using both the Petroff and Kudoh methods.
Implementation of Kudoh culture in Venezuela,Warao Amerindian population
Jacobus De Waard et al. (not yet published)
Picture: Jacobus De Waard, Venezuela
No. of sputum Samples
Acid-fast staining smear +
Culture Kudoh
Culture Petroff
Positive Total
Hospital setting
315 56 71 68 77
Field conditions
651 38 46 N.D 46
Results: Kudoh culture Jacobus De Waard et al. (unpublished)
• Kudoh swab method is as sensitive as the Petroff decontamination procedure in the diagnosis of pulmonary TB.
• It represents an alternative method for culturing mycobacteria that could reduce labor in laboratories with a high volume of sputum samples, especially appropriate for rural settings without the proper infrastructure for traditional culturing.
• The method needs no laboratory equipment, and the minimal sample manipulation reduces biosecurity risks, so that it can be easily taught to technicians without experience in tuberculosis microbiology.
Considered for operational research
Slide DST
Slide DST
• Culture perform directly on slide smear-positive samples
• Counting acid-fast micro-colonies under microscope
• A. Hamid Salim et al., Int J Tuber Lung Dis 2006. Early and rapid microcopy-based diagnosis of true treatment failure and MDR-TB.
• Sensitivity and specificity RIF:96%
• Sensitivity and specificity INH: 99% and 64%
Picture: A. van Deun
Considered for operational research
Early and rapid microcopy-based diagnosis of true treatment failure and MDR-TB, 2006, Int J Tuber Lung Dis 10 (11):1248-1254. A. Hamid Salim, et al
Summary
Microscopy• Bleach concentration• Auramine staining• FDA staining• 2 slides• Positivity threshold
Culture and DST• MODS• Thin-layer agar• Nitrate reductase• Redox indicators• Kudoh method• Slide culture
ImplementedImplementedOperational researchImplementedImplemented
Not adoptedAdopted for field testConsidered for field testNot adoptedConsidered for operational researchConsidered for operational research
Conclusion
• Some tools exist– Some ready for implementation– Some require more field testing– Some require more evidence
• Why so slow ? • Why so neglected ?